LEPROSY STATUS REPORT ON

Transcription

1 erican Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; the R f Korea; the Lao People s Democratic Republic; Macao, China; Malaysia; the Northern Mariana Islands; the Marshall Islands; the Federated States of ronesia; Mongolia; Nauru; New Caledonia; New Zealand; Niue; Palau; Papua New Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; omon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; American Samoa; Australia; Brunei Darussalam; Cambodia; China; Coo s; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; the Republic of Korea; the Lao People s Democratic Republic; Macao, China; Ma Northern Mariana Islands; the Marshall Islands; the Federated States of Micronesia; Mongolia; Nauru; New Caledonia; New Zealand; Niue; Palau; Pa STATUS REPORT ON Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; A Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; the Republ ea; the Lao People s Democratic Republic; Macao, China; Malaysia; the Northern Mariana Islands; the Marshall Islands; the Federated States of Micro LEPROSY ngolia; Nauru; New Caledonia; New Zealand; Niue; Palau; Papua New Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Isla elau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; American Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; Fre ynesia; Guam; Hong Kong, China; Japan; Kiribati; the Republic of Korea; the Lao People s Democratic Republic; Macao, China; Malaysia; the Norther riana Islands; the Marshall Islands; the Federated States of Micronesia; Mongolia; Nauru; IN New THE Caledonia; WHO WESTERN New Zealand; PACIFIC Niue; REGION Palau; Papua New Gu Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; American Samo tralia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; the Republic of Korea; t ple s Democratic Republic; Macao, China; Malaysia; the Northern Mariana Islands; the Marshall Islands; the Federated States of Micronesia; Mongoli ru; New Caledonia; New Zealand; Niue; Palau; Papua New Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokela ga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; American Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Poly m; Hong Kong, China; Japan; Kiribati; the Republic of Korea; the Lao People s Democratic Republic; Macao, China; Malaysia; the Northern Mariana s; the Marshall Islands; the Federated States of Micronesia; Mongolia; Nauru; New Caledonia; New Zealand; Niue; Palau; Papua New Guinea; the P s; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and Futuna; American Samoa; Austra nei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; the Republic of Korea; the Lao Pe ocratic Republic; Macao, China; Malaysia; the Northern Mariana Islands; the Marshall Islands; the Federated States of Micronesia; Mongolia; Nauru; edonia; New Zealand; Niue; Palau; Papua New Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tu uatu; Viet Nam; Wallis and Futuna; American Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; H WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific g, China; Japan; Kiribati; the Republic of Korea; the Lao People s Democratic Republic; Macao, China; Malaysia; the Northern Mariana Islands; the M nds; the Federated States United of Nations Micronesia; Avenue Mongolia; Nauru; New Caledonia; New Zealand; Niue; Palau; Papua New Guinea; the Philippines; the Pitca 1000 Manila, Philippines nds; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam; Wallis and World Futuna; Health American Organization Samoa; Australia; Brunei Daruss Tel. No.: (63-2) bodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Japan; Kiribati; Regional the Republic Office for the of Western Korea; Pacific the Lao People s Democratic R Fax No.: (63-2) stoptb@wpro.who.int Website: Macao, China; Malaysia; the Northern Mariana Islands; the Marshall Islands; the Federated States of Micronesia; Mongolia; Nauru; New Caledonia; N land; Niue; Palau; Papua New Guinea; the Philippines; the Pitcairn Islands; Samoa; Singapore; Solomon Islands; Tokelau; Tonga; Tuvalu; Vanuatu; V ISBN ; Wallis and Futuna; American Samoa; Australia; Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, Ch 2002 Manila, Philippines

2 STATUS REPORT ON Leprosy IN THE WHO WESTERN PACIFIC REGION 2002 World Health Organization Regional Office for the Western Pacific Manila, Philippines

3 Prepared by Leprosy Elimination Unit WHO Western Pacific Regional Office In collaboration with Dr P.S. Rao, WHO Consultant ACKNOWLEDGEMENTS We would like to thank all leprosy programme managers and statisticians from all the countries and areas of the Western Pacific Region for providing appropriate data for this document. WHO Library Cataloguing in Publication Data Status Report on Leprosy in the WHO Western Pacific Region, Leprosy epidemiology. 2. Western Pacific ISBN (NLM Classification: WC 335) The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland, or to the Regional Office for the Western Pacific, Manila, Philippines, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. World Health Organization 2004 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this report do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation country or area appears, it covers countries, territories, cities or areas. Published in the Philippines Updated information on leprosy in the Western Pacific Region is available on the website ii

4 CONTENTS Acknowledgements Figures and tables Abbreviations Summary ii v vi vii Part I REGIONAL OVERVIEW OF LEPROSY ELIMINATION IN THE WESTERN PACIFIC 1 1 Introduction 3 2 Highlights of the year Epidemiological situation 6 Prevalence and elimination status 6 New case detection 8 Post-elimination trends of prevalence and new case detection in some countries 11 Other information and indicators 12 4 Programme activities 14 Strengthening national programmes 14 Special projects 14 Other special projects 15 Collaboration with other partners 16 5 Challenges 18 6 Future priorities and activities 19 Countries in which leprosy has not been eliminated (0.01% of the regional population) 19 Countries that failed to sustain elimination 20 Countries that achieved elimination at national level 20 Resource requirements 21 iii

5 Part II ANNEXES 23 Annex 1 Leprosy elimination accomplishments at sub-national level among large countries in the Western Pacific Region at the end of Annex 2 Western Pacific Region of WHO Categorization of countries/areas according to the number of leprosy cases reported in iv

6 FIGURES AND TABLES FIGURES Figure 1 Leprosy situation in the Western Pacific Region, end of 2002 x Figure 2 Leprosy prevalence rates and multidrug therapy coverage in the Western Pacific Region, Figure 3 Distribution of the number of registered cases and the prevalence rates per of the eight countries in the Western Pacific Region, Figure 4 Distribution of new cases of leprosy detected in Figure 5 New case detection rate in Figure 6 Leprosy new case detection rate per in the Western Pacific Region, Figure 7 Trend of prevalence rate after elimination in some large countries 11 Figure 8 Trend of new case detection rate after elimination in some large countries 11 Figure 9 Trend of prevalence rate after elimination in some small countries 12 Figure 10 Trend of prevalence rate in countries that have yet to reach elimination 19 TABLES Table 1 Table 2 Table 3 Table 4 Latest notification of leprosy cases and monitoring indicators by country, 2002 ix Trend of the prevalence and new case detection in the Western Pacific Region, Elimination status at national level among the member countries of Western Pacific Region 8 Proportion of MB, disability grade 2 and children below 15 years among the new cases, v

7 ABBREVIATIONS HEC LEC LEM MB MDT NGO PB P/D ROM SAPEL WHO Health education campaign Leprosy elimination campaign Leprosy elimination monitoring Multibacillary Multidrug therapy Non-governmental organization Paucibacillary Prevalence/detection ratio Rifampicin-ofloxacin-minocycline Special Action Project for the Elimination of Leprosy World Health Organization vi

8 SUMMARY This Status Report on Leprosy in the WHO Western Pacific Region 2002 is based on the information collected from 37 countries/areas 1 of the Region and other sources. A total of 34 countries/areas have sent annual leprosy data for Guam, Japan and the Commonwealth of the Northern Mariana Islands have not sent the annual leprosy data for However, these three countries, with a combined population of million, have reported only 17 new cases and seven prevalent cases in The number of cases registered at the end of 2002 was with a prevalence rate of 0.065/ The prevalence rate continued to decline by 5.8% compared to that of 2001 and by 85.6% compared to that of The estimated population of the Region for the year 2002 was 1.7 billion. Out of the 35 countries/areas that eliminated leprosy as a public health problem (prevalence of less than one case per population) at the end of 2001, 33 countries/areas have sustained the elimination status in Kiribati and Papua New Guinea have lost the elimination status due to an increase in prevalence rate to more than 1 per at the end of Besides, leprosy has continued to be a public health problem in the Federated States of Micronesia and the Marshall Islands. Nine countries have reported zero prevalence and new case detection. The number of cases registered at the end of 2002 was with a prevalence rate of 0.065/ The prevalence rate continued to decline by 5.8% compared to that of 2001 and by 85.6% compared to that of The number of registered cases was less than 10 in 19 countries. There were only three countries with more than 1000 registered cases. The number of new cases reported in 2002 was 7187, with a new case detection rate of 0.42 per population. The new case detection rate has declined for the fifth consecutive year since The case detection rate declined by 4.5% compared to 2001 and by 49.4% compared to This declining trend may be attributed to the good coverage and effectiveness of multidrug treatment regimens on transmission of disease. The prevalence/ detection (P/D) ratio at 1.5 showed a marginal decline in 2002, indicating 1 Throughout the text, the word country will be used to indicate either country or area. vii

9 administration of short duration treatment regimens and good compliance to treatment. During the year 2002, one leprosy elimination campaign (LEC), one health education campaign (HEC), one rapid survey of endemic pockets and one Special Action Project for Elimination of Leprosy (SAPEL) were completed, as well as screening of selected populations in the Federated States of Micronesia, Kiribati and the Marshall Islands that resulted in detection of 209 new cases. Since 1996, 82 special projects have been implemented, which detected 5065 cases covering about 38.8 million population. Furthermore, a national leprosy awareness campaign in the Federated States of Micronesia and a leprosy awareness week in Cambodia were also conducted in An interim evaluation of the implementation of a post-elimination surveillance system pilot project in Cambodia was carried out in Some problems in organizing referrals and proper documentation of activities were noticed. Similarly, leprosy elimination monitoring (LEM) exercises were undertaken in Cambodia and Papua New Guinea as part of an overall country programme evaluation. The Regional prevalence rate that reached elimination level in 1991 has declined continuously thereafter. The new case detection rate that fluctuated soon after elimination has started to decline from However, the rate of fall of both prevalence and case detection rates are now slowing down. A similar picture is emerging in some of the large countries like the Lao People s Democratic Republic, the Philippines and Viet Nam, after they reached elimination In China and the Republic of Korea, elimination was accomplished prior to In these two countries, with an initial fall after elimination, both prevalence and case detection rates have stagnated since Future activities will be focused in the two countries that have defied efforts to reach elimination so far and those countries that have failed to sustain elimination. Besides, efforts will be made to achieve elimination at subnational level in large countries that already reached the elimination at national level. Development and implementation of comprehensive post-elimination strategies covering surveillance, independent evaluation of programme achievements, gradual integration of leprosy control activities into general health services, and other residual problems like rehabilitation will be the major concern during the post-elimination phase in the Region. viii

10 Table 1 Latest notification of leprosy cases and monitoring indicators by country, 2002 Prevalence New case detection Country Population x 1000 No. Rate x No. Rate x MB a % Dis b % Child c % Cases cured P/D d ratio American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam (2001) Hong Kong (China) Japan (2001) Kiribati Republic of Korea Lao People s Democratic Republic Macao, China Malaysia Northern Mariana Islands (2001) Marshall Islands Federated States of Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Summary Note: Figures in ( ) mean year of latest data. a Proportion of Multibacillary cases. b Proportion of cases with grade 2 disability among new cases. c Proportion of children younger than 15 years among new cases. d Ratio between prevalent cases at the end of the year and the number of new cases detected during the year. ix

11 Mongolia People's Republic of China Republic of Korea Macao, China Lao People's Democratic Republic Cambodia Hong Kong Viet Nam Philippines Brunei Malaysia Singapore Australia Legend cases per (27 countries) cases per (4 countries) Less than 10 cases (Nauru and Palau) 1 or more cases per (4 countries) Japan Northern Mariana Islands Marshall Islands Guam Federated States of Micronesia Palau Kiribati Papua New Guinea Nauru Solomon Islands Tuvalu Vanuatu Fiji New Caledonia New Zealand World Health Organization Regional Office for the Western Pacific STB and Leprosy Elimination Focus Figure 1 Leprosy Situation in the Western Pacific Region End of 2002 Cook Islands Tokelau Wallis and Futuna American Samoa French Polynesia Samoa Niue Tonga Pitcairn Islands The designation on this map do not imply the expression of any opinion on the part of the Regional Director concerning the legal status of any country or territory or the delimitation of its frontiers. PIC group of islands not to scale. Note: Shaded areas are outside the WHO Region for the Western Pacific. x

12 Regional Overview of Leprosy Elimination in the Western Pacific PART I

13

14 1 INTRODUCTION The development of multidrug therapy (MDT) for the treatment of leprosy in the early 1980s was an important milestone in combating the disease. The WHO Western Pacific Region comprises 37 countries and areas with a population of approximately 1706 million. 2 The Region contains very large countries such as China and Japan representing, respectively, 75% and 8% of the total regional population and very small countries, of which 30 contribute to only 3% of the total population. Eight countries have populations of more than 10 million and six have a population of between one and 10 million. Of the remaining 23 countries with a population of less than one million, six have a population of more than and 17 have a population of less than , of which eight have or less. These countries are scattered in the north, west, central and south Pacific. The development of multidrug therapy (MDT) for the treatment of leprosy in the early 1980s was an important milestone in combating the disease. MDT implementation started in control programmes in and was used worldwide by The reduction in prevalence achieved during this first phase was so impressive that elimination of leprosy as a public health problem considered to be a prevalence rate of less than one case per population became an attainable target. Based on this, the Forty-fourth World Health Assembly, held in 1991, adopted a resolution aiming for global elimination of the disease by the year Although the elimination goal was achieved at global level by the end of 2000, a few countries have not reached the goal at their national level. Therefore, in 1999, the target date for reaching elimination was extended to In the Western Pacific Region, MDT implementation began in It reached 10% coverage in 1988 and almost 100% by 1994, coinciding with a decrease in prevalence rate (Figure 2). In 1991, elimination was achieved at regional level and at national level by 15 countries. By the end of 2000, 2 As furnished by countries in their annual reports for 2001 and in Demographic Tables, , WHO Western Pacific Regional Office where countries did not furnish data. 3

15 35 countries in the Region had already reached elimination. At the end of 2002, only two small countries in the Region have not accomplished the elimination target and two other countries that reached elimination earlier have failed to sustain it Rate per % Figure 2 Leprosy prevalence rates and multidrug therapy coverage in the Western Pacific Region, Multidrug therapy coverage Prevalence rate

16 2 HIGHLIGHTS OF THE YEAR 2002 Further decline in prevalence and new case detection rates at regional level. Elimination status was sustained in 33 of the 35 countries that reached elimination. LEM exercise in Cambodia and Papua New Guinea validated programme achievements. Post-elimination surveillance system pilot project in Cambodia was evaluated on an interim basis. National leprosy awareness campaign was launched in the Federated States of Micronesia. National level leprosy orientation training workshops were conducted in the Federated States of Micronesia and the Marshall Islands. Special projects like LEC, HEC, SAPEL and rapid survey were implemented in endemic pockets of Cambodia, China, and the Lao People s Democratic Republic. Geographic information system (GIS) was developed in Cambodia. Prevalence in Kiribati and Papua New Guinea rebounded, resulting in loss of elimination status. 5

17 3 EPIDEMIOLOGICAL SITUATION The prevalence decreased from in 1991 to in 2002 and the prevalence rate dropped continuously from 0.45 to in the same period, representing a decrease of 86%. Table 1 summarizes the latest available data on leprosy by country, as of the end of Out of 37 countries, 34 sent data using the annual statistic form of the Western Pacific Regional Office and/or the format communicated by WHO Headquarters. Only Guam, Japan and the Northern Mariana Islands, with a combined population of million, have not sent the data. PREVALENCE AND ELIMINATION STATUS Prevalence The elimination of leprosy as a public health problem is considered achieved when the prevalence rate is less than one per at national level. The prevalence decreased from in 1991 to in 2002 and the prevalence rate dropped continuously from 0.45 to in the same period, representing a decrease of 86%. China, the Philippines and Viet Nam contributed mostly to this latest reduction in the prevalence rate. Only three countries have more than 1000 registered cases. The Philippines with 3334 has the largest number of registered cases, followed by China (3263) and Viet Nam (1269). When comparing rates, however, it is evident that some small countries (Federated States of Micronesia, the Marshall Islands and Nauru) also have a serious leprosy problem (Figure 3) although by absolute numbers, their contribution to the regional problem was negligible. 6

18 Cambodia China Nauru Marshall Islands Federated States of Micronesia Papua New Guinea Philippines Figure 3 Distribution of the number of registered cases and the prevalence rates per of the eight countries in the Western Pacific Region, 2002 Registered cases per 1000 Prevalence rate per Viet Nam Table 2 Trend of the prevalence and new case detection in the Western Pacific Region, Regional Registered cases Newly detected cases Population Rate per Rate per Year (000s) Number Number (0.45) (0.97) (0.28) (0.89) (0.23) (0.71) (0.24) (0.81) (0.19) (0.74) (0.16) (0.80) (0.15) (0.83) (0.12) (0.64) (0.09) 9494 (0.57) (0.07) 8360 (0.49) (0.07) 7409 (0.44) (0.07) 7187 (0.42) With the introduction of single dose treatment for single lesion and oneyear duration for MB, the duration of the disease has been reduced to between one day and 12 months. As a result, the prevalence is converging with detection. Elimination status Elimination at regional level was achieved in 1991, but at national level, only 15 countries reached elimination level. The number of countries that reached elimination at national level rose to 35 by the end of By the end of 2002, the two countries, Federated States of Micronesia and the Marshall Islands, had still not achieved elimination. Two countries, Kiribati and Papua New Guinea, which reached elimination in 2000, have failed to sustain it by the end of This is mostly due to increased case detection, delays in completion of treatment and update of records and the small population of Kiribati. Two countries, Nauru and Palau, which have small populations and less than 10 registered cases, are considered to have achieved elimination. To date, 99.99% of the regional population lives in countries that have eliminated the disease. 7

19 Table 3 Elimination status at national level among the member countries of Western Pacific Region Thirty-five countries that achieved elimination, representing 99.9% of the regional population American Samoa, Australia, Brunei Darussalam, Palau, a Cambodia, China, Cook Islands, Fiji, French Polynesia, Guam, Hong Kong (China), Japan, Kiribati, Republic of Korea, Lao People s Democratic Republic, Malaysia, Macao (China), Mongolia, Nauru, a New Caledonia, New Zealand, Niue, Northern Mariana Islands, Papua New Guinea, Philippines, Pitcairn Islands, Samoa, Singapore, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu, Viet Nam, and Wallis and Futuna Two countries that did not yet achieve elimination The Federated States of Micronesia and the Marshall Islands Two countries that failed to sustain elimination Kiribati and Papua New Guinea a Less than 10 cases. Sub-national elimination has been reached at regional level in the Philippines; at provincial level in the Lao People s Democratic Republic, Viet Nam, Cambodia (in 21 of the 24 provinces covering 95% of the population); and at county level (except in a few counties) in China. However, these five countries contribute to 79% of the total prevalent cases in the Region at the end of 2002 (Annex 1). NEW CASE DETECTION There were 7187 new cases detected in 2002 corresponding to a new case detection rate of 0.42 per population, compared to new cases detected in 1991 with a rate of 0.97 (Table 2). Four countries contributed to 83% of all new cases detected. The highest proportion of 34% of all new cases was detected in Philippines (Figure 4 and Annex 2). Other countries Papua New Guinea 8% 9% Philippines Figure 4 Distribution of new cases of leprosy detected in 2002 Cambodia 10% 34% 16% Viet Nam 23% China 8

20 The new case detection rates of countries varied from zero to per in Six countries have reported case detection rates of more than 10/ with the highest rate reported in the Marshall Islands. Another eight countries reported case detection rates between one and 10/ Of the remaining 23 countries, 10 countries reported case detection rates between 0.01 and 0.99/ and 10 countries reported that no new cases were detected and three countries did not submit reports (Figure 5). Marshall Islands Federated States of Micronesia Figure 5 New case detection rate in 2002 Kiribati Nauru Palau Papua New Guinea Northern Mariana Islands (2001) Samoa Solomon Islands Cambodia French Polynesia Philippines Vanuatu Lao People's Democratic Republic Viet Nam New Caledonia Malaysia Guam (2001) Fiji Western Pacific Region average China Hong Kong (China) Singapore Republic of Korea New Zealand Brunei Darussalam Australia Japan (2001) Note: No cases were detected in American Samoa, Cook Islands, Macao (China), Mongolia, Niue, Pitcairn Islands,Tokelau, Tonga, Tuvalu and Wallis and Futuna Rate per

21 The 2002 new case detection rate is the lowest reported during the last 12 years and has declined by 49.4% since 1997 (Figure 6 and Table 2). The latest decline was mostly due to decreases in numbers of new cases in the Philippines (190), Viet Nam (178) and China (80). The new case detection rate has varied from 0.97 in 1991 to 0.42 per in The rate has generally remained stable up to 1997 with only small variations between years. A marked reduction of 23% occurred in 1998 and the case detection rate declined continuously thereafter (Figure 6) Rate per Figure 6 Leprosy new case detection rate per in the Western Pacific Region, New case detection includes patients that showed the onset of the disease during 2002 (incident cases) as well as in previous years (backlog cases that remained undetected). The exact proportion of the backlog cases among the new cases is not known. Case detection is also influenced by the intensity of programme activities, service coverage and the reporting system, as well as sensitivity and specificity of the diagnosis. Therefore, the detection rate may not represent the true incidence and the degree of transmission of infection in the community. However, analysis of data from 1991 to 2002 revealed a significant declining trend in the new case detection rate that might lead to interruption of transmission and freedom from leprosy in the long run. 10

22 POST-ELIMINATION TRENDS OF PREVALENCE AND NEW CASE DETECTION IN SOME COUNTRIES The prevalence and new case detection trends in countries with large populations indicate a consistent and continuous decline (Figures 7 and 8) Rate per Figure 7 Trend of prevalence rate after elimination in some large countries China Malaysia Republic of Korea Viet Nam Rate per Figure 8 Trend of new case detection rate after elimination in some large countries China Malaysia Republic of Korea Viet Nam However, there were wide fluctuations in countries with small populations, sometimes even crossing over the elimination level, especially in countries with populations of less than (Figure 9). These trends will be closely monitored and appropriate action will be initiated where necessary. 11

23 Rate per Figure 9 Trend of prevalence rate after elimination in some small countries Guam Northern Mariana Islands Samoa Vanuatu OTHER INFORMATION AND INDICATORS Cases cured A total of 192 cases completed treatment in Countries such as Cambodia, China, Malaysia, Papua New Guinea, the Philippines and Viet Nam with large case burden have not reported treatment completion. Prevalence/detection ratio On average, the ratio between the prevalence and the detection was 1.5 and remained stable in comparison to One-year fixed duration MDT for MB cases was introduced in 1997 to 98, so the ratio should not exceed 1.5 for the countries that introduced the one-year policy. The ratio was very high in the Republic of Korea (24.7), Singapore (8.3), Hong Kong (China) (6.5), Malaysia (5.7) and New Caledonia (3.5) (Table 1). This indicates that, in these countries, patients are treated longer than necessary or registers are not updated or the patients are irregular in taking their treatment, or a combination of these factors. MB, child and disability grade 2 proportions Among new cases, the proportion of MB, the disability grade 2 and those involving children younger than 15 years showed no change from The proportion of MB cases among the new cases has averaged 71%, from 1994 to 2002, peaking at 80% in Visible disability, expressed as grade 2, represented on average 13% and showed little variations. The 12

24 percentage of new cases involving children younger than 15 years was 7%, on average, and ranged from 3% to 9% between 1994 and 2002 (Table 4). This perhaps indicates that recent transmission of infection was recorded at a very low level. Table 4 Proportion of MB, disability grade 2 and children below 15 years among the new cases, New cases a Multibacillary Disability grade 2 Children <15 Year No. No. % No. % No. % Totals and Averages a The numbers are those reported by the countries in the year considered. Countries that did not report are not included. 13

25 4 PROGRAMME ACTIVITIES During 2002, four special projects were completed, of which one was SAPEL, one was LEC and two were LEC-like projects (rapid survey of high endemic pockets and health education campaigns). STRENGTHENING NATIONAL PROGRAMMES Ten countries, Cambodia, China, Kiribati, the Lao People s Democratic Republic, the Marshall Islands, Micronesia, Papua New Guinea, the Philippines, Samoa and Viet Nam were provided with technical assistance, in order to strengthen programme capability in planning and implementing special projects among other activities, between 1996 and These countries benefited the most from special projects, especially Cambodia and the Philippines, which achieved elimination during SPECIAL PROJECTS Leprosy Elimination Campaigns (LEC) and Special Action Project for Elimination of Leprosy (SAPEL) In 2002, WHO Regional Office for the Western Pacific focused its efforts in assisting the two countries that did not achieve elimination in 2001, as well as assisting some of the countries that reached elimination prior to These countries, with the assistance of WHO and non-governmental organizations (NGOs), and through their own resources, developed and implemented LECs and SAPELs. During 2002, four special projects were completed, of which one was SAPEL, one was LEC and two were LEC-like projects (rapid survey of high endemic pockets and health education campaigns). The projects covered a population of about two million and detected 177 new cases. Cambodia implemented two such projects; China and the Lao People s Democratic Republic each implemented one. The first such projects were implemented in By 2002, 82 projects had been completed, covering a population of 38.8 million and detecting 5065 new cases. The figures represented 7.3% of the cumulative new 14

26 cases detected in the Region during these seven years. The countries that most benefited from these projects were Cambodia and the Philippines, covering 97% and 26%, respectively, of their total populations. OTHER SPECIAL PROJECTS The Federated States of Micronesia, Kiribati and the Marshall Islands, which had high prevalence rates, implemented special projects to accelerate and achieve elimination by the year Federated States of Micronesia. A two-year project that started in 1996 was implemented to screen the whole population twice, in order to detect cases and treat those detected. Preventive therapy, consisting of Rifampicinofloxacin-minocycline combination for adults and rifampicin alone for children younger than 15, was also administered twice to all healthy people during screening. Preventive therapy coverage of the population with one dose was 87% and 54% with two doses. As a result of the project, 288 new cases were detected in 1996, 123 in 1997 and 39 in 1998, representing more than 85% reduction in new cases from 1996 to A national level leprosy orientation-training workshop was held in May 2002 and a national leprosy awareness campaign was launched in October 2002, boosting the efforts to reach elimination in time. Screening of some high endemic villages was carried out in 2002 and detected 22 new cases. The number of new cases detected has increased continuously since 1999 compared to the rate of increase in Kiribati. The country has implemented a project similar to that of Federated States of Micronesia, with mass screening and administration of preventive therapy to selected populations. Mass screening was started in To date, the project has detected 150 new cases, of which 135 were found in the first round. A second round of mass screening and administration of preventive therapy continued in 1999 and detected 24 new cases. As a result, the country was able to achieve elimination by the end of Screening of populations in high endemic villages was done in 2002 and detected 6 new cases. Due to an increase in the number of new cases detected in 2002, the prevalence rate has increased, resulting in loss of elimination status by the end of Marshall Islands. The project of screening the whole population and administering preventive therapy to the contacts of past and present cases of leprosy, which was started in 1998, was completed by April A total of 222 new cases of leprosy were detected and treated during the survey. 15

27 A national level leprosy orientation training workshop was held in May 2002 and about 4775 school children were screened during the year, detecting four new cases. There was a perceptible fall in prevalence and new case detection rate at the end of 2002 to 8.57/ and 92.86/ respectively from and in Post-elimination surveillance system Guidelines were developed by the Western Pacific Regional Office in 1999 for a post-elimination surveillance system based on the establishment of referral centres for case diagnosis and management, referral of suspected cases from the periphery to the central level, notification of individual cases to the central level, mapping of the notified cases, integrating leprosy information into the general health information system, sustaining leprosy awareness in the community and general health staff and evaluation. Based on these guidelines, a pilot project of the post-elimination surveillance system was started in selected provinces of Cambodia in An interim evaluation of the implementation of the post-elimination surveillance system pilot project in Cambodia was undertaken in This evaluation identified some problems related to referrals and documentation of procedures. Recommendations included some changes in the referral mechanism and improvements in carrying out monitoring and supervision activities. Geographic information system (GIS) was developed and two officers at central level were trained to operate the system. In 2002, the surveillance system was extended to three more provinces. The pilot project that was started in selected provinces of Viet Nam in 2001 has been extended to some more provinces. Leprosy Elimination Monitoring (LEM) The Leprosy Elimination Monitoring exercise was carried out by external consultants in Cambodia and Papua New Guinea as part of the programme evaluation process. The consultants validated the program achievements in general and made valuable recommendations, in order to further improve the programme performance. COLLABORATION WITH OTHER PARTNERS Continuous collaboration has been maintained with Sasakawa Memorial Health Foundation (SMHF), which funded the activities developed in Cambodia, Papua New Guinea and Federated States of Micronesia. A 16

28 partnership programme has been developed with the Pacific Leprosy Foundation to assist South Pacific countries, especially Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu. Coordination meetings with governments and NGOs for leprosy elimination were held in Cambodia, the Lao People s Democratic Republic and the Philippines. 17

29 5 CHALLENGES The epidemiology of the disease itself is still a problem because, to date, there is no effective way to measure the level of infection and the incidence of the disease in the community. In some countries, accessibility to health care services is restricted because of poor communication and vast distances (between the small islands countries, for instance). In other countries (such as Papua New Guinea and the Philippines) some places are not accessible because of security concerns. Therefore, patients living in difficult-to-reach areas now represent an important proportion of the total caseload and it will be harder to detect these patients. A few countries (Hong Kong [China], Malaysia, the Republic of Korea and Singapore) still have a prevalence and detection ratio higher than two, indicating that patients are treated longer than necessary and that they are inflating the overall prevalence. Moreover, the implementation of the 12- month duration regimen for MB is progressing slowly in certain areas. Countries like Cambodia and the Lao People s Democratic Republic that reached elimination by 1998 are still dependent to a large extent on external resources in running their programmes to sustain elimination. There are a large number of patients who were declared cured but require care after cure in the treatment of complications, like reactions and plantar ulcers. Similarly, there are a large number of cured cases that need to be rehabilitated, physically and socio-economically, because of their disabilities developed due to the disease. The epidemiology of the disease itself is still a problem because, to date, there is no effective way to measure the level of infection and the incidence of the disease in the community. This is further complicated by the very long incubation period of the disease and the process of self-healing of many single lesions, as well as the tendency for the patients to hide their disease because of the social stigma attached to leprosy. 18

30 6 FUTURE PRIORITIES AND ACTIVITIES COUNTRIES IN WHICH LEPROSY HAS NOT BEEN ELIMINATED (0.01% OF THE REGIONAL POPULATION) Due to high baseline endemicity and the long incubation period of the disease, the disease may persist for a longer period in the Federated States of Micronesia and Marshall Islands compared to other countries. The trend of prevalence for the last eight years in the Marshall Islands and Federated States of Micronesia was declining after an initial rise due to special projects implementation (Figure 10). However, the prevalence rate has stagnated in the Federated States of Micronesia since 1998 due to an increase in the number of new cases detected. Due to high baseline endemicity and the long incubation period of the disease, the disease may persist for a longer period in these two countries compared to other countries. However, these two countries will be further supported to continue the control activities, such as screening of high-risk groups, training and information, education and communication (IEC) and they will be closely monitored on their progress towards elimination Rate per Figure 10 Trend of prevalence rate in countries that have yet to reach elimination Federated States of Micronesia Marshall Islands

31 COUNTRIES THAT FAILED TO SUSTAIN ELIMINATION Two countries, Kiribati and Papua New Guinea, which reached elimination by the end of 2000, have failed to sustain elimination by the end of In Kiribati, it was mainly due to the small population of the country and the small increase in the number of cases detected. In Papua New Guinea, besides detection of more new cases, a large number of cases were not able to complete the treatment in the prescribed time and/or the registers are not kept up to date. These two countries will also be supported in strengthening supervision and other control activities and will be closely monitored. COUNTRIES THAT ACHIEVED ELIMINATION AT NATIONAL LEVEL Sub-national elimination LECs targeting pockets of high prevalence within large countries to detect hidden cases and/or SAPELs targeting difficult-to-reach areas/populations will be carried out in order to achieve sub-national elimination (Cambodia, China, the Lao People s Democratic Republic, Papua New Guinea, the Philippines and Viet Nam). Post-elimination surveillance system The ongoing post-elimination surveillance system pilot projects in selected provinces of Cambodia, the Lao People s Democratic Republic and Viet Nam will be subjected to an in-depth evaluation and further action will be taken based on the evaluation results. Integration of leprosy control activities into the general health services To sustain elimination and progress towards freedom from leprosy cost effectively, the present leprosy control activities need to be integrated into the general health services at all levels and aspects including health personnel, utilization of health facilities, information system and drug distribution. Assuming that complete integration means that there will be no staff or health facility exclusively working for leprosy, the present country programmes will be analyzed and encouraged to integrate leprosy activities into their general health services through a phased/step-by-step approach. 20

32 Validation of leprosy elimination At present, a country is considered to have achieved elimination based on the statistical information provided by the national government, without further validation. The completeness and correctness of the statistical information in most countries are in general not satisfactory because of the inherent weaknesses in the operation of health information systems. There are also no specific and sensitive laboratory tools to measure the levels of leprosy infection in the community, in order to understand the dynamics of transmission and to correlate with prevalence. The cross-sectional surveys could measure the prevalence, but the sample sizes required for estimated prevalence of less than one per population with clustering of cases, will be huge and not practicable. Although exercises like independent leprosy elimination monitoring (LEM) might help to evaluate the programme performance, they would not tell us for definite that the prevalence in the community is the same as the reported prevalence. Efforts will be made to review the LEM document for its adaptation to suit low and very low prevalent situations and apply the same to validate programme achievements. RESOURCE REQUIREMENTS To carry out the leprosy strategic plan for the period , US$ 2.2 million is required of which US$ is needed in each of the first two years ( ) and US$ in each of the last two years ( ). Furthermore, the assistance provided by NGOs to national governments should be kept at current levels, until a cost-effective surveillance system is established with integration of leprosy control activities into general health services and the high pockets of leprosy have been eliminated. 21

33

34 Annexes PART II

35

36 Annex 1 Leprosy elimination accomplishments at sub-national level among large countries in the Western Pacific Region at the end of 2002 Population reached elimination Country Population (million) Regional Provincial District Cambodia 12.5 No regions 96.4% 96.2% China No regions 100.0% 99.3% (counties) Lao People s Democratic Republic 5.4 No regions 98.8% No information Papua New Guinea % 71.8% No information Philippines % 94.4% No information Viet Nam 77.2 No regions 100.0% 98.5% 25

37 Annex 2 Western Pacific Region of WHO Categorization of countries/areas according to the number of leprosy cases reported in 2002 Number of cases 0 Population (thousands) (9.02%) Cases 0 Prevalent cases New cases Countries/areas Australia, Cook Islands, Japan, Macau, Mongolia, New Zealand, Niue, Population (thousands) 3252 (0.19%) Cases 0 Countries/areas American Samoa, Cook Islands, Macau, Mongolia, Niue, Pitcairn Islands, Tokelau, Pitcairn Islands, Tokelau, Tonga, Tonga, Tuvalu, Wallis and Futuna (10) Tuvalu, Wallis and Futuna (12) (0.12%) 47 (0.43%) American Samoa, Brunei Darussalam, (9.58%) 50 (0.69%) Fiji, Guam, Nauru, New Caledonia, Australia, Brunei Darussalam, Fiji, Guam, Hong Kong (China), Japan, Nauru, New Northern Mariana Islands, Palau, Caledonia, New Zealand, Northern Mariana Samoa, Vanuatu (10) Islands, Palau, Singapore, Vanuatu (13) (0.70%) 254 (2.3%) French Polynesia, Hong Kong (2.84%) 148 (2.05) (China), Kiribati, Federated States of French Polynesia, Kiribati, Republic of Korea, Marshall Islands, Samoa, Solomon Islands (6) Micronesia, Marshall Islands, Singapore, Solomon Islands (7) (5.57%) 2868 (25.99%) Cambodia, Lao People s Democratic (2.80%) 1723 (23.90%) Republic, Malaysia, Republic of Cambodia, Lao People s Democratic Republic, Malaysia, Federated States of Micronesia, Korea, Papua New Guinea (5) Papua New Guinea (5) > (84.58%) 7866 (71.28%) China, Philippines, Viet Nam (3) (84.58%) 5283 (72.33%) China, Philippines, Viet Nam (3) Total Notes: There are only 8 countries with more than 100 prevalent or new cases. Majority of the countries (22) were with less than 10 prevalent cases. 26